Neuro Flashcards
1
Q
L3 root compression? (4)
A
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
2
Q
L4 root compression? (4)
A
Sensory loss over anterior knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
3
Q
L5 root compression? (4)
A
Sensory loss over dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
4
Q
S1 root compression?
A
Sensory loss over posterolateral aspect of leg and lateral foot
Weakness of plantarflexion
Reduced ankle reflex
Positive sciatic nerve stretch test
5
Q
When to consider MRI for root compression?
A
If symptoms persist for 4-6 weeks despite analgesia, physiotherapy and exercises
6
Q
Initial signs of SACD development in B12 deficiency (e.g. 2 years after gastrectomy for cancer)? (3)
A
Loss of ankle reflexes
(knee reflexes may be brisk)
Loss of vibration and pin prick
Wide-based ataxia
7
Q
Difference between migraine symptoms in kids and adults? (3)
A
In kids shorter lasting, more commonly bilateral, and GI disturbance more prominent
8
Q
Can aura for migraine occur without headache?
3 things which make the sensory/motor disturbance an aura?
A
Yes
- Fully reversible
- Develop over at least 5 mins
- Last 5-60 mins
9
Q
5 common migraine auras?
A
- Double vision
- Visual symptoms affecting one eye (scintillating scotoma)
- Motor weakness
- Poor balance
- Decreased level of consciousness
10
Q
Becker/Duchenne MD:
- inheritance? problem with what gene?
- Symptoms they have in common? (3)
- Differences between them? (2)
- Difference between these and myotonic dystrophy?
A
Autosomal Dominant
Dystrophin gene - large membrane protein which attaches membrane to actin in muscle
- Progressive proximal muscle weakness
- Calf pseudohypertrophy
- Gower’s sign: child uses arms to stand from squatted position
- Duchenne onset from 5 y/o, Becker’s is later in teens
- 30% in Duchenne have intellectual impairment, this is very rare for Becker
Myotonic dystrophy - muscles have increased tone, unable to relax
11
Q
What muscles are generally spared in MND?
A
Extraocular - eye movements spared
12
Q
Loss of thumb abduction after colles #?
A
Median nerve injury
13
Q
How does ulnar nerve damage present in hand?
A
Weakness of 4th and 5th fingers, with loss of sensation of these fingers also front and back
14
Q
MRI with/without contrast should be used for demyelinating lesions e.g. MS?
What is seen on MRI with MS?
On CSF?
A
WITH contrast
MRI:
- High signal T2 lesions
- Periventricular plaques
- Dawson fingers: hyperintense lesions perpendicular to corpus callosum extending up like little fingers
CSF:
- Oligoclonal bands
- Increased intrathecal synthesis of IgG
15
Q
5 month old with seizures and developmental delay - EEG shows hypsarrhythmia?
What is the typical seizure of this condition like?
Prognosis?
A
Infantile spasms (West Syndrome)
Salaam attacks - flexion of head, trunk and limbs with extension of arms
(lasts 1-2 secs and repeated up to 50 times)
Poor prognosis - progressive mental handicap
16
Q
What diet is good for treatment-resistant epilepsy in kids?
A
Ketogenic
17
Q
1st step in first aid of patient with raised ICP?
A
Head elevation to 30 degrees
18
Q
Causes of raised ICP? (5)
Symptoms? (5)
A
- Idiopathic intracranial hypertension
- Traumatic head injuries
- Infection (e.g. meningitis)
- Tumours
- Hydrocephalus
Headache Vomiting Reduced consciousness Papilloedema Cushing's triad - widening pulse pressure, bradycardia, irregular breathing
19
Q
Investigations for raised ICP? (3)
A
- CT/MRI key to see underlying cause
- Increased opening pressure on LP
- Invasive - catheterisation of lateral ventricle to measure pressure
20
Q
Management of raised ICP?
A
(Ix and treat underlying cause)
- Head elevation to 30 degrees
- IV mannitol
- Controlled hyperventilation (reduce pCO2, cerebral vasoconstriction, temporary lowering of ICP)
- Removal of CSF (e.g. repeated LP in idiopathic ICH, or ventriculoperitoneal shunt)
21
Q
Is Guillain Barre painful? Cranial nerve involvement? Autonomic involvement? Why can papilloedema occur? Ix? (2)
A
65% experience back/leg pain
Cranial: diplopia, bilateral facial nerve palsy, oropharyngeal weakness common
Autonomic: urinary retention, diarrhoea
Papilloedema: decreased CSF resorption
Ix:
- LP: raised protein but normal WBC
- nerve conduction studies: decreased motor nerve velocity
22
Q
Apart from weakness, what other symptoms can people get with Bells’ palsy?
Management? (2)
When should they show signs of improvement?
Prognosis?
A
- Post-auricular pain (often precedes paralysis)
- Altered taste
- Dry eyes
- Hyperacusis
- Prednisolone PO within 72 hours of onset
- artificial tears and eye lubricants
<3 weeks - if not improvement refer urgently to ENT
Most recover fully in 3-4 months, if untreated 15% have permanent mod-sev weakness
23
Q
Should prokinetics e.g. metoclopramide be used in kids with GI disturbance in migraines?
A
No - they should be used with extreme caution in kids due to common SE of asthenia, parkinsonism and depression
(reserved for chemo etc)
(also they are generally CI in epilepsy)
24
Q
Tuberous sclerosis:
- inheritance?
- 2 neurological features?
- 5 derm features?
- 1 in eye?
- 1 in kidney?
A
Autosomal Dominant
Neuro:
- Epilepsy
- Intellectual impairment
Skin:
- Depigmented ash-leaf macules (fluoresce under UV)
- Roughened patches of skin over lumbar spine (Shagreen patches)
- Angiofibromas in butterfly distribution over nose (adenoma sebacum)
- Subungal fibromas
- Cafe-au-lait macules
Eye:
- Retinal hamartoma
Kidney:
- PKD
25
What are the 4 Parkinsons Plus syndromes?
- Multiple System Atrophy
- Lewy Body Dementia
- Progressive Supranuclear Palsy
- Corticobasal degeneration
26
Apart from parkinsonism, what 3 other things are seen in progressive supranuclear palsy?
Response to drugs?
- Impairment of vertical gaze: down worse than up (complain of trouble reading/descending stairs)
- Postural instability and falls (stiff, broad-based gait)
- Cognitive impairment (frontal lobe dysfunction)
Poor response to L-dopa
27
Motor weaknesses in common perineal nerve injury? (3)
Sensory loss (2)
What muscle compartments will have wasting? (2)
Weakness of:
- foot dorsiflexion
- foot eversion
- extensor hallucis longus
Sensory loss:
- dorsum of foot (incl 1st web space)
- lower lateral part of leg
Wasting of:
- anterior and lateral leg compartment muscles
(anterior = deep; lateral = superficial)
28
What blood component is it important to check in workup of TIA? Why?
Glucose
Hypoglycaemia can cause focal neurological symptoms and mimic TIA
29
How is a TIA defined?
New definition is tissue based:
A transient episode of neurological dysfunction caused by focal brain, cord or retinal ischaemia, without acute infarction
30
Immediate management of a TIA?
Referral if suspected TIA in last 7 days?
If suspected TIA >7 days ago?
What is a crescendo TIA and what is the referral for this?
Referral if suspected cardiac/carotid source of stroke?
Driving after suspected TIA?
RULE OUT BLEED!!!
Give aspirin 300mg immediately
(unless bleeding disorder, already taking low-dose aspirin or it is CI)
- Be seen in <24 hours by stroke specialist
- Be seen asap in <7 days by a stroke specialist
Crescendo TIA = >1 TIA - admit for observation urgently
- also admit for observation urgently
Don't drive until after being seen by specialist
31
Antithrombotic therapy post-TIA?
| When is carotid endarterectomy performed?
Clopidogrel 1st line
Aspirin + dipyramidole 2nd line (if cannot tolerate clopiogrel e.g. diarrhoea)
- If stenosis >70% and stroke/TIA in carotid territory
32
How to tell if a 3rd nerve palsy is a surgical problem?
3rd nerve palsy due to posterior communicating artery aneurysm?
Other causes of 3rd nerve palsy? (5)
Pupil is dilated
Painful - pain around/behind the eye and/or generalised headache, 3rd nerve palsy and dilated pupil
- diabetes
- vasculitis (GCA, SLE) or others (MS, amyloid)
- uncal herniation through tentorium if raised ICP
- cavernous sinus thrombosis
- Weber's syndrome: ipsilateral 3rd nerve palsy with contralateral hemiplegia - midbrain stroke
33
Post-LP headache:
- when does it come on?
- how long does it last?
- what position is it worse in?
- if it doesn't resolve in set time period?
24-48 hours (occurs due to low pressure)
- <72 hours
- worse when upright (better lying down)
- If >72 hours then treatment indicated to prevent subdural haematoma:
blood patch, epidural saline or IV caffeine
34
Scoring system for suspected stroke?
After FAST
ROSIER:
First exclude hypoglycaemia, then stroke is likely if any of the following:
- LOC/syncope
- Seizure activity
- Asymmetrical facial, arm or leg weakness
- Speech disturbance
- Visual field defect
35
Ix for suspected stroke?
Non-contrast CT
36
Who can initiate treatment for Parkinson's?
| 1st line?
Specialists only
1st line:
- if motor symptoms affect QOL: levodopa
- if not affecting QOL: dopamine agonist, MAO-B inhibitor or levodopa
37
Unwanted effects of levodopa? (5)
Why can it not be stopped immediately?
What type of Parkinsonism is it not used in?
```
Dyskinesia (involuntary writhing)
'On-off' effect
Dry mouth
Postural hypotension
Psychosis
```
DO NOT stop levodopa immediately - risk of acute dystonia
NOT used in drug-induced parkinsonism
38
What dopamine agonists are mainly used in Parkinsons?
| Why try to avoid ergot-derived ones such as cabergoline or bromocriptine?
Ropinorole or Apomorphine
Cabergoline/Bromocriptine can cause retroperitoneal, cardiac and pulmonary fibrosis. Before commencing baseline echo, creatinine and CXR should be taken and monitor patients closely
39
Example of a MAO-B inhibitor?
| How does it work?
Selegiline
Inhibits breakdown of dopamine. Higher doses also prevent breakdown of serotonin and NA (antidepressant)
40
2 examples of COM-T inhibitors?
| How is it used?
Tolcapone, entecapone
In conjunction with levodopa as it prevents breakdown of dopamine
41
What type of drugs are used for drug-induced parkinson's?
Antimuscarinics - procyclidine, trihexyphenidyl etc
Help tremor and rigidity
42
For each of these where is the lesion and describe the aphasia:
- Wernicke's?
- Broca's?
- Conduction?
- Global?
Wernicke's (Receptive):
- Lesion in superior temporal gyrus (MCA)
- Comprehension impaired, speech is fluent but makes no sense - 'word salad'
Broca's (Expressive):
- Inferior frontal gyrus (MCA)
- Comprehension normal, speech is non-fluent and halting
Conduction:
- Lesion in arcuate fasciculus (between broca and wernicke)
- speech fluent but repetition is poor - aware of errors they are making
Global:
- Lesion affecting all 3
- Severe receptive and expressive aphasia - can communicate using gestures
43
MS management:
- acute relapse?
- for fatigue?
- for spasticity?
- bladder dysfunction?
- oscillopsia (visual field oscillation)?
Relapse: IV methylpred 5 days - shortens relapse but no effect on recovery
Fatigue:
1. Rule out anaemia, thyroid, depression
2. Amantadine
3. Mindfulness, CBT
Spasticity:
1. Baclofen
2. Gabapentin
3. Diazepam, Dantrolene or Tinzadine
Bladder - urgency, frequency, overflow, incontinence etc:
1. bladder USS to assess residual volume
2. If normal residual volume, anticholinergics may help frequency
3. If significant residual volume - intermittent self-catheterisation
(be aware anticholinergics may worsen symptoms)
Oscillopsia:
- Gabapentin
44
DMARDs for MS?
B interferon
Glatiramer acetate - immunomodulator
Natulizumab - recombinant MAb, against leucocytes, prevents crossing of BBB
Fingolimod - prevents lymphocytes leaving lymph nodes
45
Hoarseness and uvula deviating to right?
Left vagus nerve lesion
uvulAWAY from side of lesion
46
What tracts are affected in SACD?
DCML - proprioception, vibration
| Lateral corticospinal - spasticity, brisk knee reflexes, positive babinski
ankle jerks typically lost
47
Chronic form of Guillain barre?
Chronic inflammatory demyelinating polyneuropathy
48
Causes of CNIII palsy?
| What is seen?
Causes:
- diabetes
- Uncle herniation through tentorium cerebelli in raised ICP
- Posterior communicating artery aneurysm (painful)
- vascular (vasculitis, cavernous sinus thrombus, Weber Syndrome - midbrain stroke)
Signs:
- down and out eyeball
- dilated
- ptosis
- pupil won't constrict to light, but light shone in that eye causes consensual constriction
49
```
Cerebral venous sinus thrombosis:
- presentation of sagittal?
- cavernous?
- lateral?
Gold standard Ix?
```
All have insidious onset over hours-days of severe headache, N&V
Sagittal:
- may cause seizures and hemiplegia
- parasagittal wartershed infarcts may be seen
Cavernous:
- periorbital oedema
- ophthalmoplegia - 6th nerve before 3rd and 4th
- central retinal vein thrombosis
- 5th nerve involvement may cause hyperaesthesia of upper face/eye pain
Lateral:
- 6th and 7th nerve palsies
Ix: MRI venogram
50
Degenerative cervical myelopathy Ix?
| Rx?
MRI
Decompression surgery - best outcome within 6 months
Physio should only be initiated by specialists as manipulation can worsen spinal cord damage
51
Cushing's triad?
Bradycardia
Irregular breathing
Hypertension with a WIDE pulse pressure
52
Left sided facial weakness - what side and U/L motor neurone would be affected and how can you discriminate?
Left facial weakness
Right Upper motor neurone
If the forehead muscles are spared
Left Lower motor neurone
If the forehead muscles are affected
53
Causes of bilateral facial muscle weakness?
```
GBS
Sarcoidosis (parotid swelling)
Lyme disease
Bilateral acoustic neuromas (NF2)
Bell's palsy - 1% Bells Palsy are bilateral but Bells Palsy causes 25% bilateral facial weakness
```
54
Causes of LMN facial palsy?
```
Bell's palsy
Ramsay Hunt Syndrome
Acoustic neuroma
Parotid tumour
HIV
Diabetes
MS (may also cause UMN)
```
55
Can Bell's Palsy be painful?
Yes in 50% there may be some pain
If no vesicles in ear though then not Ramsay Hunt
56
How to test if fluid from er/nose is CSF?
Bedside - glucose - esp in trauma
Gold standard - beta-2 transferrin (but this takes about a week to get back)
57
MND - features of:
- ALS?
- Primary Lateral Sclerosis?
- Progressive Muscular Atrophy?
- Progressive Bulbar/Pseudobulbar Palsy
ALS:
- UMN and LMN signs
- familial - chromosome 21
- 25% have bulbar onset
PLS:
- UMN signs only
Progressive muscular atrophy:
- LMN signs only
- Distal before proximal
- best prognosis
Progressive Bulbar Palsy:
- Palsy of muscles of chewing, swallowing and face - brainstem motor nuclei
- worst prognosis
(bulbar = LMN, pseudo bulbar = UMN of corticobulbar tracts)
58
Difference between spasticity and rigidity?
Spasticity:
- caused by motor tract UMN e.g. cortex, brainstem, corticospinal tract
- On quick movement there is initial resistance which melts away, no resistance on slow movement ('clasp knife')
Rigidity:
- caused by extrapyramidal e.g. basal ganglia
- resistance on slow movement, and doesn't melt away on quick movement
59
MOA of ondansetron?
| Where does it act?
5-HT3 antagonist
CTZ in the medulla
60
1st line management of absence seizures?
Sodium valproate or ethosuxomide
61
If patient is brought into A&E in a status, most important 2 causes to rule out first?
Hypoxia
| Hypoglycaemia
62
Precipitants of migraines?
CHOCOLATE
```
Chocolate
Hangovers
Orgasms
Cheese/caffeine
Oral contraceptives
Lie-ins
Alcohol
Travel
Exercise
```
63
Which type of Parkinson's treatment is most linked with impulse control issues?
Dopamine agonists
Bromocriptine, Ropinirole, Pramipexole, Cabergoline
Gambling, sexual, food etc
64
4 features of acoustic neuroma?
Tinnitus
Vertigo
Hearing loss
Absent corneal reflex
65
ACA stroke?
MCA stroke?
PCA stroke?
Basilar stroke?
ACA:
- contralateral hemiparesis/sensory
- lower extremity worse
MCA:
- contralateral hemiparesis/sensory
- upper worse then lower
- contralateral homonymous hemianopia
- Aphasia
PCA:
- contralateral homonymous hemianopia with macular sparing
- visual agnosia
Basilar:
- locked in syndrome
66
Anterior inferior cerebellar stroke?
Lateral Pontine Syndrome
- ipsilateral facial pain/temperature
- Contralateral pain/temperature loss
- ipsilateral ataxia, nystagmus
so far same as PICA, but with addition of...
- ipsilateral facial paralysis and deafness
67
Posterior inferior cerebellar stroke?
Lateral medullary syndrome
Wallenberg syndrome
- ipsilateral facial pain and temperature loss
- contralateral limb pain and temperature loss
- ipsilateral nystagmus
68
Weber's Syndrome?
Stroke of PCA branches that supply midbrain
- ipsilateral CNIII palsy
- contralateral weakness of both limbs
69
1st line and 2nd line options for generalised tonic clonic seizures?
1st - valproate
2nd line - lamotrigine, carbamazepine
70
1st line options for absence seizures?
| What might make them worse?
1st - valproate or ethosuximide
(Valproate esp good if co-existent tonic-clonic)
DO NOT give carbamazepine - might make it worse
71
1st line and 2nd line options for myoclonic seizures?
1st - valproate
2nd - lamotrigine, clonazepam
72
1st line and 2nd line options for focal seizures?
1st line - carbamazepine or lamotrigine
2nd line - levetiracetam, oxcarbazepine, valproate
73
When can antiepileptic drugs be stopped and over how long should they be withdrawn?
Seizure free for >2 years and stopped over 2-3 months
74
Anticoagulation therapy post-stroke if AF is the cause?
Warfarin or DOAC
| Xa inhibitor e.g. apixaban, or direct Thrombin inhibitor e.g. dabigatran
75
Stroke:
- Apart from thrombolysis, what should be started in the first couple of days?
- What is the exception to this?
- Long-term treatment after acute stroke?
- BP target after stroke?
Aspirin within 24 hours
Statin within 48 hours
(or alternative anti platelet if aspirin not tolerated)
If on anticoagulant (e.g. for prosthetic valve) stop it for 7 days and start aspirin after this
If from AF - start warfarin/DOAC
If not - start clopidogrel
After 2 weeks
Aim for BP<130/80, try to avoid B blockers
76
Common peroneal nerve lesion features?
- weakness dorsiflexion (deep)
- weakness eversion (superficial)
- weakness extensor hallucis longus
- wasting of anterior tibial and peroneal (lateral) muscles
- sensory loss dorsum of foot and lateral lower leg
77
What is seen on LP with GBS?
| What antibodies can be tested for?
increased protein
normal WCC
anti-ganglioside
78
Side effects phenytoin? (6)
```
Gingival hyperplasia
Hirsutism
Megaloblastic anaemia
Peripheral neuropathy
Lymphadenopathy
Osteomalacia (enhanced VitD metabolism)
```
79
in TIA, what are the only 3 occasions aspirin should not be given immediately?
1. Patient has bleeding disorder or is taking anticoagulant - admit immediately for imaging to rule out stroke
2. Patient is already taking low-dose aspirin - just continue this until seen by specialist
3. Aspirin is contraindicated
80
Red flags which prompt immediate referral in trigeminal neuralgia?
- sensorineural hearing loss
- symptoms or FHx of MS
- optic neuritis
- only affecting ophthalmic division
- bilateral
- sensory change
- <40 y/o
81
What is important to tell pts taking levodopa?
| What is used as rescue medication for acute 'off' states?
Must be taken at same time each day
Apomorphine
82
Anti-emetic to be used for Parkinson's?
Domperidone
83
Features of corticobasal degeneration?
Parkinson's plus sydrome
Rigidity and muscle weakness in one limb with apraxia (loss of purposeful movement)
Phantom limb phenomenon
84
Difference between postural tremor and intention tremor?
| Causes of each
Postural - worse when holding arms out, persists during movement but doesn't get worse during the movement
Causes: anxiety, alcohol withdrawal, hyperthyroid, salbutamol, caffeine, lithium, valproate, TCA, essential
Essential - AD
Intention - task oriented, made worse throughout range of movement
Causes: cerebellar disease (MS, stroke), Wilson's disease
85
Causes of dystonia (not acute like antipsychotics):
- cervical?
- eyes?
- jaw?
- vocal cords?
- limbs?
Cervical - muscle strain, OA
Eyes - myasthenia, dry eyes
Jaw - myasthenia, TMJ dysfunction
Vocal cords - laryngitis, polyps
(coarse, strained voice)
Limbs - overuse, nerve entrapment
86
Management of dystonia?
Anti-spasmodic: Baclofen
Focal: botulinum injection
Acute: Procyclidine
87
What is a chorea?
Non-rhythmical, irregular, purposeless movement that flits and flows from one body part to another
(e.g. facial grimacing, writhing of shoulders, rapid movements of fingers)
88
Huntington's:
- Inheritance?
- age of onset?
- Presentation?
- management?
AD - CAG repeat in Chr4 producing a neurotoxin resulting in degeneration of striatum
Usually 4th decade - presents earlier with each generation (genetic anticipation)
Triad of emotional, cognitive and motor neurone disturbance
Early: clumsy, chorea, irritability, depression, agitation
Late: chorea, myoclonus, rigidity, fits, dementia, loss of ability to speak/swallow
Management: supportive - lifespan 15 years
89
Sydenhams chorea?
Self limiting chorea seen in children after strep throat infection
90
What is myoclonus
Sudden, involuntary muscle jerks - can be normal, abnormal if >5 of these movements
91
Drugs that can cause parkinsonism?
Metoclopramide
Antipsychotics]
Amiodarone
92
Causes of myoclonus?
```
Genetic - benign essential (same as tremor)
Stroke, SOL, head injury
CJD
Levodopa
Alcohol withdrawal
Liver/renal failure
Hyponatraemia
```
93
What are tics?
Primary tic disorder?
Secondary?
involuntary stereotyped movements or vocalisations, which are unable to be suppressed. Attempts to suppress cause anxiety and discomfort, which is relieved upon completing the tic
Primary: Tourettes - start in childhood
Secondary: autism, huntington's, wilson's, haemochromatosis - present in childhood or adulthood
94
MND is linked to which type of dementia?
Frontotemporal
95
Antibodies for myasthenia gravis?
anti-AChR
| anti-MuSK
96
Antibodies for LEMS?
| Management?
Anti-P/Q VGCC antibodies
3,4 - diaminopyradine
IVIG
97
Occipital lobe seizures?
Flashes
Spots
Lines
General visual disturbances
98
SE valproate?
```
Reversible hair loss
Ataxia
Tremor
Pancreatitis
Liver failure
Weight gain
Teratogen - NTD
Thrombocytopaenia
Oedema
```
99
SE lamotrigine? (4)
Maculopapular rash
SJS
DIC
Photosensitivity
100
SE levetiracetam?
mood swings
101
SE carbamazepine?
Impaired balance
Leucopaenia
Double/blurred vision
Impaired balance
102
What increases risk of SUDEP?
poorly controlled
Smoking
Use of illicit drugs
103
DVLA and epilepsy:
- first unprovoked seizure?
- epilepsy and seizure?
- withdrawing medications?
First unprovoked seizure:
- if no structural problem and no epileptic activity on EEG then 6 months
- if not then 12 months
With epilepsy:
- can't drive for a year
- no HGV for 5 years
Withdrawing medication:
- cannot drive whilst meds are being withdrawn
- cannot drive for 6 months after last dose
104
What 2 anti epileptics are P450 inducers?
| What one is an inhibitor?
Inducer: carbamazepine and phenytoin
Inhibitor: valproate
105
Can valproate and carbamazepine be given to breastfeeding mothers?
Yes
106
10 features featuring pseudo seizures?
```
pelvic thrusting
family member with epilepsy
female
crying after attack
don't occur when alone
gradual onset
no tongue/tip of tongue biting
no incontinence
eyes open
rhythmic/pattern
```
107
Lhermitte and Uhtoffs signs?
in MS:
Lhermitte - electric shock down spine and arms when head bent forward
Uhtoffs - worse in head and exercise
108
Timescale for episodes in MS to be diagnostic?
Must last at least 1 hour and be at least 30 days apart
109
If someone has optic neuritis, how many plaques on MRI suggest MS?
>3 plaques in white matter give 50% chance of MS in 5 years
110
LP with MS?
IgG oligoclonal bands (that aren't in serum)
111
Nerve roots:
- musculocutaneous?
- axillary?
- radial?
- median?
- ulnar?
Musculocutaneous: C5-7
Axillary: C5/6
Radial: C5-T1
Median: C6-T1
Ulnar: C8-T1
112
Nerve roots:
- lateral cutaneous nerve of thigh?
- femoral?
- obturator?
- sciatic?
- Tibial?
- common fibular?
- superficial fibular?
- deep fibular?
Lat cut: L2/3
Femoral: L2-4
Obturator: L2-4
Sciatic: L4-S3
Tibial: L4-S3
Common fib: L4-S2
Sup fib: L4-S1
Deep fib: L4-S1
113
Causes of mono neuritis multiplex?
- diabetes
- rheumatoid
- carcinomatosis
- Vascilitis: wegeners, PAN
- HIV
114
Presentation of polyneuritis?
Symmetrical and widespread neuropathy, usually begins distally with glove and stocking sensory loss and progressive muscle weakness
Diabetes, B12, wegener's, HIV, syphilis, alcohol, isoniazid, paraneoplastic
115
What is seen on LP of meningitis caused by:
- virus?
- bacteria?
- TB?
- aseptic?
Virus: high WCC, lymphocytes, normal protein and glucose
Bacteria: Neutrophils, positive Gm stain, high protein, low glucose
TB: lymphocyte predominant WCC, high protein, low glucose
aseptic: all essentially normal, perhaps minimally increased protein
116
What causes progressive multifocal leukoencephalopathy??
JC virus
| Immunocompromised pts
117
How many attacks of migraine for prophylaxis?
2 or more per month
118
Prophylaxis for women with predictable menstrual migraine?
Triptan to be taken on those days
119
Triptans:
- MOA?
- SE?
- CI?
5-HT1 agonists
SE: 'triptan effect' - tingling, heat, heaviness in chest, pressure, tightness of throat
CI: IHD or cerebrovascular disease
120
Prophylaxis of chronic tension headaches?
Acupuncture
low dose amitriptyline now widely used but no evidence base
121
Features of cluster headaches?
Occur in clusters over a 1-3 month period
Intense, sharp stabbing pain around one eye with lacrimation and conjunctival injection and nasal stuffiness. May have mitosis and ptosis. Lasts 15 mins-2 hours
Acute: 100% oxygen, sc triptan
Prophylaxis: verapamil
122
Features of paroxysmal hemicrania?
Similar to cluster headaches, but no cluster of attacks.
Continua version - attacks grow in intensity
Rx: indomethacin
123
Features of TMJ dysfunction?
| Management?
Cyclical/constant facial pain upon using the jaw, may have abnormal sound when using, tender of masticatory muscles. Often a psych background
NSAIDS
Rest, physio
124
Management of cerebral venous sinus thrombosis?
General treatment of raised ICP - head tilt etc
Warfarin +/- heparin
Can be thrombolysed if needed
125
Ix for SAH?
Acute management?
How is hydrocephalus treated?
secondary prevention?
1. CT
2. LP 12 hours later - xanthochromia
- > refer to neurosurgery once confirmed
Once confirmed - CT angio for cause
Acute management:
- induce hypertension with IV saline (maintain perfusion)
- Nimodipine (21 days, prevents vasospasm)
Hydrocephalus: extra-ventricular drain
Endovascular clipping/coiling
126
Complications of SAH?
Rebleed - 50% chance in 6 months
Delayed ischaemia from vasospasm - typically 3-12 days later
-> nimodipine
Hydrocephalus - due to blockage of arachnoid granulations, usually transient, shunt if required
Hyponatraemia - due to SIADH
127
Management of subdural haemorrhage?
1st - burr hole craniotomy
| 2nd - craniotomy
128
Management of epidural haematoma?
Clot evacuation and ligation of middle meningeal artery
129
What tumours commonly metastasise to brain?
```
Lung
Breast
Kidney
Colon
Melanoma
```
130
Most common primary brain tumour of adults? 4 grades?
Imaging?
Histology?
Astrocytoma:
Grade 1 - benign
Grade 2 - largely benign, small malignant potential
Grade 3 - anapaestic astrocytoma (2 year survival)
Grade 4 - glioblastoma multiforme - highly invasive, can develop de novo or from premalignant precursors, survival = 1 year
Imaging: solid tumour with necrotic core and oedema
Histology: pleomorphic cells and necrotic areas
131
2nd commonest primary brain tumour? Histology?
Meningioma - arises from dura - round shape
Spindle cells and calcified psammoma bodies
132
Commonest primary brain tumour in kids? Histology?
Pilocytic astrocytoma
Histology: rosenthal fibres
133
Medulloblastoma - what is it? histology?
Infratentorial brain tumour in kids. Aggressive, spreads through CSF.
Small, blue cells
134
Tumour commonly found in 4th ventricle?
| How does it present?
Ependymoma
Hydrocephalus
135
What is an oligodendroma?
| Histology?
Benign, slow growing frontal lobe tumour
Histology: calcifications with fried egg appearance
136
Where do craniopharyngiomas arise?
Rathke's pouch in sellar region
137
1st line imaging for suspected brain tumour?
MRI
138
Management of idiopathic intracranial hypertension?
Weight loss
| Acetazolamide
139
Tabes dorsalis?
Neurosyphilis
| Loss of DCML modalities only (proprioception and vibration)
140
Anterior cord syndrome?
Due to anterior spinal artery occlusion
Bilateral spastic paresis
Bilateral loss of pain and temperature
(due to loss of lateral spinothalamic and lateral corticospinal)
141
Central cord syndrome?
What is affected and why?
Presentation?
Usually due to whiplash or in elderly with cervical spinal stenosis
Corticospinal - upper limbs affected (as more central)
Spinothalamic - lost as fibres decussate
Presentation: upper limb weakness and band-like loss of pain, temperature and gross touch
142
Ix for spinal CORD injury with ?
CT
MRI for kids
(for trauma - XR first, CT if XR abnormal or if symptoms/signs of spinal cord injury)
143
What tumour is assoc w von Hippel Lindau?
| Histology?
Haemangioblastoma of cerebellum
Foam cells
144
Who needs to test for brainstem death?
2 separate doctors from 2 separate specialties e.g. neurological and anaesthetist
145
```
What is pituitary apoplexy?
RF?
Presentation?
Ix?
Management?
```
Sudden enlargement of a pituitary tumour (usually non-functioning macro adenoma) secondary to haemorrhage or infarction
RF: hypertension, pregnancy, trauma, anticoagulation
Pres:
- sudden onset 'thunderclap' headache but felt behind the eye
- vomiting and neck stiffness
- bitemporal superior hemianopia
- extra ocular nerve palsy
- features of hypopituitarism (hypotension, hyponatraemia etc)
Ix: MRI
Management:
- urgent steroid replacement due to loss of ACTH
- careful fluid balance
- surgery
146
Loss of finger abduction and thumb adduction?
T1
147
Head injury:
- criteria for immediate CT? (6)
- criteria for CT within 8 hours? (4)
Immediate:
- GCS <13 initially
- GCS <15 2 hours post-injury
- suspected skull fracture
- post-traumatic seizure
- focal neurological deficit
- >1 episode of vomiting
8 hours:
- age 65+
- Hx of bleeding/clotting disorders
- dangerous mechanism of injury
- >30 mins retrograde amnesia before event
148
Focal seizure:
- lip smacking, plucking?
- posturing?
- paraesthesia?
- flashes/floaters?
- head/leg movements?
- hallucinations?
- epigastric rising?
- post-ictal dysphasia?
Lip smacking (automatisms) - temporal lobe
Posturing = frontal lobe
Paraesthsia = parietal lobe
Flashes/floaters = occipital lobe
Head/leg movements = frontal lobe
Hallucinations = tempora; lobe
Epigastric rising = temporal lobe
Post-ictal dysphasia = temporal lobe
149
Hyponatraemia following head injury?
SIADH
150
Head injury - diplopia and difficulty opening mouth?
| Orbital blowout fracture - what bone?
Zygoma fracture
Blow out: maxilla
151
Ix for MS?
MRI brain and spine with contrast
152
Food drop, loss of hip abduction, all reflexes intact?
L5 radiculopathy
153
Initial steps in haemorrhage stroke/haemorrhagic transformation?
Stop/reverse any anti platelet/anticoagulant drugs
| Maintain BP to a target 140mmHg systolic
